These results highlight several public health issues. First, the majority of adolescents who endorsed a pattern of symptoms consistent with opioid dependence (83%), abuse (84%), or subthreshold use (91%) did not receive any substance abuse service or treatment; an even higher proportion (89%, dependence; 96%, abuse; 97%, subthreshold) reported no perceived need for treatment. These estimates are of concern because they suggest that adolescents meeting criteria for OUD are unlikely to use treatments even when they are available. Prior research also shows that family income and private insurance are not associated with substance abuse treatment use (Mojtabai, 2005
), but having public health insurance is associated with treatment use (Wu, Kouzis, & Schlenger, 2003
). Reasons for a low rate of treatment use by privately insured adolescents were unclear. Future studies should examine the kinds of treatment offered privately vs. publicly, and whether privately insured patients differentially seek treatment for mental problems rather than substance use, or are less likely to have substance abuse treatment supported by their insurance plans.
Another issue concerns stigma
(didn't want others to find out; concerned with negative opinions) and not perceiving having problems
(wasn’t ready to stop using; could handle the problem; didn't need treatment). Failure to seek treatment therefore might be attributed to fears of stigma and lacking knowledge about dangers of drug use. Additionally, the ease of availability of prescription opioids from family members/friends plus the perception that legal —perscription” opioids are safer than —illicit” drugs (ONDCP, 2007
) might affect motivation to seek help. As shown here, few adolescents meeting criteria for dependence (4%), abuse (1%), or subthreshold use (1%) reported perceived need for treatment. Nevertheless, while studies have shown that adolescents with mental health concerns often —thought or hoped that the problem would go away,” —did not know where to get help,” and —were reluctant to disclose mental or substance use concerns to their doctors” (Klein, McNulty, & Flatau, 1998
; Samargia, Saewyc, & Elliott, 2006
), this study suggests the encouraging message by showing that parents’ communications with adolescents about dangers of substance use are associated with increased odds of substance abuse treatment use and with decreased odds of reports of unmet need for treatment. Such communication might improve adolescents’ understanding of health risks from drug use or increase willingness to disclose health concerns by lessening worries of rejection.
Further, blacks, Hispanics, and adolescents in non-metropolitan areas may face additional barriers to treatment and need continued research and outreach efforts to improve their treatment use. For example, black and Hispanic adolescents have been found to be more likely than white adolescents to report being socially isolated and not wanting to get help for substance use (Windle, Miller-Tutzauer, Barnes, & Welte, 1991
). However, in adult studies, findings have suggested that blacks are as or more likely than whites to use substance abuse treatment (Wu et al., 2003
; Wu & Ringwalt, 2004
). One direction for future research is to determine whether whites tend to use treatment from mental health sectors while blacks differentially receive treatment through the criminal justice system as they age (National Center on Addiction and Substance Abuse, 2010
; Wells, Klap, Koike, & Sherbourne, 2001
). Therefore, drug use among adolescent blacks seems to differ from their adult counterparts, and efforts for reducing drug use during adolescence are critically important.
Overall, need factors (comorbid SUD, criminal justice system involvement) increase treatment use, although adolescents also report psychological barriers to treatment use (stigma, lacking insight, unaware of sources of help). It appears that only when adolescents develop severe or externalizing problems (e.g., legal) do they come to the attention of adults and trigger treatment entry. Lastly, self-help groups are a common source of help; thus, research is recommended to evaluate the degree to which they respond to adolescents’ needs (Kelly & Myers, 2007
These findings should be interpreted with caution. NSDUH relies on self-reports, which can be influenced by memory errors and under-reporting. Institutionalized and homeless adolescents were not included in NSDUH; the findings do not apply to them. Additionally, data on quality of care and motives for nonmedical use are not collected by NSDUH. Further, like other national surveys, SUDs in NSDUH are based on fully standardized questions designed to operationalize DSM-IV criteria for SUDs, and they have not been validated by clinicians. Prior research shows that the NSDUH methodology generates rates of substance use and dependence similar to estimates from the National Comorbidity Survey (Kandel, Chen, Warner, Kessler, & Grant, 1997
). A recent study using an interview–re-interview methodology indicates a good-to-excellent level of agreement for respondents’ reports of measures for substance use, SUD, and treatment used in NSDUH (SAMHSA, 2009
). Lastly, the small sample size of adolescents with an OUD and perceived need for treatment is a limitation of the study, and it constrains the power to identify between-group differences and to conduct detailed analyses of barriers to treatment use (e.g., whether barriers to treatment use differ by type of drugs used). Hence, p
-values have not been conservatively adjusted for multiple comparisons.
NSDUH data have strengths unavailable in small-scale studies. It has high response rates (85–87%) in adolescents, uses computer-assisted self-administration interviewing and anonymous data collection to enhance privacy, includes detailed probes and color pictures of prescription drugs to assess substance use behaviors, and applies the 2000 census to improve sample weight calibration (SAMHSA, 2009
). These features improve respondents’ reporting of substance use behaviors and the quality of the data (SAMHSA, 2009
). The results from this national sample of adolescents also have a higher level of generalizability than those of a convenient or regional sample. Given opioids’ risk for chronic addiction, HIV risk, overdose, and adverse interactions with depressants (Paulozzi et al., 2006
; Veilleux et al., 2010
), this first study of its kind in adolescents provides new, timely information to elucidate barriers to treatment use.
In conclusion, about 36% of adolescents aged 12–17 years who reported nonmedical prescription opioid use in the past year experienced symptoms of OUD, but the vast majority meeting criteria for an OUD reported no need for treatment. Efforts to increase knowledge about adverse effects of nonmedical prescription use and to reduce stigma associated with admission of a substance problem are needed if treatments are to be made truly available. Studies have shown that effective parenting (communication, parental warmth) is associated with decreased odds of adolescent substance use and that adolescents’ reluctance and difficulty in communicating their health concerns to adults serves an important barrier to treatment (Cleveland, Gibbons, Gerrard, Pomery, & Brody, 2005
; Klein et al., 1998
; Samargia et al., 2006
). Modifiable parenting factors hence deserve research to identify effective targets for intervention, and they appear to be especially beneficial to disadvantaged black adolescents (Cleveland et al., 2005
). Primary care providers who customarily see adolescents for periodic checkups can also play an important role in screening for nonmedical prescription drug use and early intervention (Winters & Kaminer, 2008
). School-based substance use prevention programs should consider including components about the dangers of nonmedical prescription drug use. Campaigns that educate people about adverse consequences of nonmedical drug use and provide treatment information might be helpful. Lastly, the scarcity of treatment research reveals that randomized trials for adolescents with OUD are critically needed and can be clinically useful (Woody et al., 2008
- Among adolescents who used nonmedical prescription opioids in the past year, 16% endorsed a pattern of symptoms consistent with DSM-IV criteria for opioid abuse or dependence, and another 20% showed subthreshold dependence use.
- The majority of adolescents with prescription opioid dependence neither used substance abuse treatment services (83%) nor perceived need for treatment related to any substance use (89%) or nonmedical opioid use specifically (96%).
- Fears of stigma or rejections, lacking knowledge about dangers of drug use, or adolescents’ reluctance in communicating health concerns to adults constitute barriers to help-seeking.
- Parents’ communications with adolescents about dangers of substance use are associated with increased odds of substance abuse treatment use; modifiable parenting factors hence deserve research to identify effective targets for intervention.
- Primary care providers who see adolescents for periodic checkups can play an important role in screening for nonmedical prescription drug use and early intervention.